Beth Chapman So, just a little bit of background.  Oh no, I’ll do the learning objectives first. So,   we’re going to think a bit about the current  levels of burnout and wellbeing in CAMHS staff,   and then use the information that we’ve  got from our mixed method study to think   about how the benefits that staff  have identified that they may get   from working in a nature-based way  might apply to their own wellbeing. We’re going to talk about the use of  patient-public engagement, at all stages   through this project, and then I’m going to touch  on a bit about the physiological mechanisms,   about how some of these benefits might work.  I know Marie-Claude just talked about some,   so we’ll build on that, obviously, we  can’t cover them all in this session. So, as we’re probably all aware here, that  there has been an increase in referrals to   CAMHS services in the UK. This was building  pre-pandemic, it escalated during the pandemic,   and it seems to be continuing now. And, in  parallel to that, we’re seeing a change in   the workforce in CAMHS, so, in some services,  there’s a definite decrease in the workforce,   in other services, there seems to be a real change  in the mix of the staff there, so possibly more   numbers of staff, but maybe less experienced.  And what – the concern is that these staff are   experiencing an effect on their wellbeing, and the  concerns around occupational stress. So we do know   that people in the mental health sector were – are  affected more than those in other health sectors   on their wellbeing, and there have been reports  around high levels of burnout in this group. So, it’s really important that we think about the  staff wellbeing, but, also, about how we’re going   to retain our staff, and if there’s anything  that we can do to improve their enjoyment of   their jobs. So, for those who don’t know about  Cornwall, so I’m from Cornwall, it’s the green bit   on the end of England, down on the South West. So,  we’re a very long, thin county. We’re really cut   off from everywhere else, apart from Devon, along  that little border, and we’re surrounded by sea. So, we have a lot of problems associated  with the coastal communities, and although   Cornwall is a really beautiful  place, it’s natural resource rich,   people – a lot of people come here on holidays,  we have massive levels of deprivation and there’s   a lot of inequality. So we have areas that  have a – have more money right next door   to those who are really deprived. And, at  the minute, or certainly up until sort of   a few weeks ago, our CAMHS service was  very predominantly clinic model based. So, CAMHS Goes Wild is a project that’s been  in the making, well, it’s come out, I guess,   in the last few years, but it’s been in my  head for much longer. This thought around,   why aren’t we delivering our services outside?  Why aren’t we making more of our environment? And   the opportunity came really in November 2021,  when everyone was emerging from the pandemic,   and I caught onto the tailcoats of senior  management, and they were – they wanted to offer   their staff something for their wellbeing. So I  thought, great, let’s get all the staff outside. And I wanted them to notice what happened  to them when they were away from their   normal clinical environment, when  they were immersed in nature,   when they were given permission to immerse  themselves in nature, and then start to wonder,   ooh, why don’t I do this more? Why – how can I  include this in my work? So, that was my agenda,   and rather than giving them all a presentation  on, “You should be doing this,” and – that’s,   kind of, what happened, we had some really  positive feedback. I didn’t really know much   about nature-based approaches, or working with  nature in clinical work, it just felt right. So, then I had a really good colleague,  Gemma Morshead, from the Trust, who – and   together we sort of co-led this project  called “CAMHS Goes Wild,” and let’s see   where this goes. We were introduced from – to  Catriona and Michéal from the Natural Academy,   and the next thing that we did was put –  co-facilitate some introductory days for   staff. So, these were a bit more structured,  giving them a bit more about the evidence,   a bit more about the how to, and  they were also really well received. And then somehow we managed to get some money  for 16 staff, it certainly wouldn’t happen at the   moment, to go on a more extended training session  with the Natural Academy of – in NatureWell   facilitated training, so that’s how that journey  happened. It’s a little bit complicated ‘cause   “CAMHS Goes Wild” was very much a, sort of,  ground up, let’s, sort of, try this, let’s   see what everyone thinks. And then, at some point,  which I’ll tell you about, I got a Mental Health   Research Initiative Associate role, which meant  that this was all underpinned by our research. So, Gemma, who I mentioned before, did do  a survey of staff, so, we were wondering,   right, we think this is a good idea, what do staff  think about working in this way? And we seemed to,   sort of, take the lid off this real  energy and enthusiasm for working   in this way. So we got this information  from surveys, we asked staff their views,   this was all very informal at this point.  But what people were saying was – well,   my favourite quote is “Working in this way,  if” – oh no, “If I could work in this way,   it would be my perfect job.” So we were  getting these really rich nuggets from staff,   that people really had to listen to, because staff  were saying, “This would make me stay in my job.” And then, of course, we wanted to know,  okay, the staff think this is a good idea,   there’s a bit of energy happening here, what do  our young people think? So, we have involved our   young people all the way through this. Again,  at the start, it was a little bit ad hoc. It   was very intuitive, it’s, like, we need to ask our  young people and the carers what they think. So,   James Welchman, who was a GP Trainee at the  time with us, organised these – a couple of   parallel – consultation groups they were  really. We had one with our young people,   and one with our parent/carers, and we just said,  “Look, we’re thinking about doing this with the   service. We’re thinking about using nature a bit  more.” We used to term “nature-based approaches”   very loosely. It was, like, “What do you think if  we used nature more in in our clinical service?”   And they were very much positive, as well, it  was like, “Yeah, well, why aren’t you doing this   already?” type thing. So, that was our initial,  kind of, permission to explore this further. I also created a film about one young  person’s particular journey. So,   some Clinicians were using nature-based approaches  already, but it was very ad hoc. It was, like,   “Well, shall we go to the beach and do our session  there? Shall we go for a walk?” But there was no,   sort of, structure or systematic way that staff  were being able to do this. But this young person   had had that, and he found it so beneficial, so we  created this film about him, and about his carer,   and it was a really useful film then to be  able to present to the board at our Trust,   and re – present to the wider system;  it was a very powerful story. And then   since then we’ve done two – we’ve done another  workshop, which I’ll talk about in a minute. So, those initial consultation that we  had with the young people, we were hearing   things like – and this is very similar to what  Marie-Claude was hearing from the Teachers, “I’m   more motivated to come to outdoor appointments.”  “I feel more relaxed outside.” “It’s easier   not to have conversations,” so it’s easier to  tolerate that silence. And there was the very,   kind of, disparaging about the clinic  rooms, which I completely understand,   “they’re depressing.” “It’s really stressful.”  “I can overhear the conversations next door.” Similar things from the parents. One parent said,   “I think my son might be doing better if he  was given the choice early about nature-based   interventions. Being given this option earlier  would have saved on wasted time.” And, of course,   that’s something really key that Managers,  Leaders, Commissioners want to hear is,   is this going to – how is this going to help  and how is this going to improve our service? We also had a stall at our big county show, which  is the Royal Cornwall Show. Thousands of people   go to that, and we were on the NHS stall, and we  just literally asked passersby, again, just their   views, “We’re thinking about using nature-based  approaches, or nature within our clinical work in   CAMHS, what do you think? Do you think it’s a good  idea?” Overwhelmingly, “Yes,” I think the people   that said “No,” said no ‘cause they were worried  about their allergies. So, there’s nothing –   nothing really came up about risk or anything like  that, it was, like, yeah, this is a good idea. So, what happened then in September 2022  was I got this Research Associate role,   which was just incredible. So it was from  PenARC, aligned with PenARC, and it gave   me a day a week to really immerse myself in  this, to become connected with other people   doing work in this area. And I had this amazing  group and team behind me, showing me , ‘cause I   was really very new to this, and we created this  research project, so, “The Provision of Community   Child and Adolescent Mental Health Services Using  Nature-Based Approaches,” looking at staff views,   experiences, and integration of training. So,  that was happening at the same time as there was   this very obvious and clear energy, and slight  cultural shift happening within the Trust, of,   ooh, this could be a possibility that  we could work slightly differently. So, now I’m going to pass over to Siobhan. Siobhan Mitchell Thanks, Beth, can everyone hear  me okay? Please wave wildly if you can’t, fab. Beth Chapman Yes. Siobhan Mitchell Oh, hi, everyone, so, yeah, I’m  Siobhan. I am a Research Fellow at the University   of Exeter. I am part of the Peninsula  Mental Health Research Initiative Team,   who were supporting Beth with her Research  Associate position. So, I’m just going to   talk a little bit about the research that  we did and then hand back over to Beth. So, the “CAMHS Goes Wild project,” we’re  aiming to, kind of, evaluate the staff views   and experiences of nature-based approaches, and  specifically, we were interested in understanding   more about how acceptable this, kind of, new way  of working might be to those working in CAMHS.   And we were also interested in what barriers, or  enablers, there might be, in terms of implementing   this way of working within CAMHS, and what  staff thought the potential outcomes might be,   both for themselves and, also, for service  users engaging in nature-based approaches. So, in terms of the study design, it  was a mixed method study, so we had   a combination of survey and interview  data. We did two waves for the survey,   so the first wave of the survey went out before  the training that Beth described earlier,   and the second wave after the training. What  we were interested in was getting two, kind of,   snapshots of data. Obviously these  weren’t far enough apart to, kind of,   evaluate the impact of the training, but they  provided us with an opportunity to observe any   differences or consistencies, in and around the  training, and, also, gave us a good opportunity   to get additional free text data  from that second wave of the survey. So, we were developing our interview  questions based on what came up in the survey,   and thinking about areas that we wanted to delve  into a little bit more. And I am going to talk   briefly about some of the key findings, both  from the survey and from the interview data. So,   first up, we’ve got the survey, so  as we started out in this research   looking to understand more about how  nature-based approaches might be used in CAMHS,   we wanted to first understand a bit more about  the wellbeing and experiences of CAMHS staff. So, as you can see from the slide, the survey  reported quite low levels of staff wellbeing,   and high levels of staff burnout, in line with  other studies that have been done in terms of   the wellbeing of staff working in these kinds  of settings. Interestingly, in terms of burnout,   only 13% reported moderate to high levels of  client-related burnout. So that suggests that,   sort of, general work and personal systems,  pressures, might be greater contributors than   specifically the fact of working with children  and young people in the mental health setting. So, this was really helpful for us in  understanding the potential role that nature-based   approaches might play. With these, kind of, new  ways of working maybe having a role to play in   the promotion of staff wellbeing, as well as that  of service users. And, also, interesting for us,   in the survey, 90% of the staff who responded were  interested in using nature-based approaches. So,   again this was a useful starting point  for us in terms of going forward. Next slide, please. So, as you can  see here, this is just showing on   some graphs the levels of wellbeing for staff.  So only 2% reporting high levels of wellbeing,   and obviously those levels  of burnout, as well, there. Next slide, please, thank you. So, in the  survey we also had some free text questions. So,   staff were asked if they could think of any  benefits, or concerns, they might have about   using nature-based approaches in their  work, and we analysed these thematically. Next slide, please, thank you. So, staff described  several potential benefits of using nature-based   approaches. So this included the idea that being  in nature might enhance both the context and the   therapeutic intervention, also, might have some  benefits in terms of resourcing and connection,   and for health and be – wellbeing,  more generally. So, for example,   being in nature might enhance aspects of  therapeutic interventions. So things like,   emotion regulation or grounding, and in  this way nature-based approaches were,   sort of, referred to as “the  second Therapist,” if you like. Next slide, please. So, staff also described some  concerns about using nature-based approaches in   their work. So this included limitations  around resource, operational challenges,   such as permissions, cultural barriers.  So things like the risk averse nature of   CAMHS as an organisation and, also, concerns  that this way of working might compromise   the therapeutic delivery. So, for example,  concerns around privacy, during the sessions. And so, we wanted to delve a little bit deeper  into the areas which came up here in the survey,   so we conducted some interviews with CAMHS  staff. The topic guides that we used covered   staff experience and attitudes towards  integrating nature-based approaches in   CAMHS. And we spoke to 14 staff across  a range of roles, levels of experience,   and work context, so, for example, being  clinic-based versus being school-based. And from our qualitative data, we generated  three key themes, which centred around, kind of,   potential barriers and enablers to implementation  of nature-based approaches in CAMHS, and, also,   around the potential benefits of working in  this way for both service users and staff.   And I’m going to talk through the,  sort of, implementation-based themes. Next slide, please, thank you. So, staff  described a tension between the culture   of CAMHS and nature-based approaches as a, kind  of, core barrier in terms of implementation. So,   with this, they included a, sort of, perceived  lack of evidence for nature-based approaches.   So similar to what we were talking  about in the previous presentation,   which really conflicted with what staff felt was  the, kind of, directive for working in CAMHS. And   staff also described how nature-based approaches  promoted a form of positive risk taking. Again,   this was, kind of, at odds with the risk  averse nature of CAMHS as an organisation,   so that was described as something that might be  challenging. And they also described uncertainty   around how nature-based approaches might  be implemented in CAMHS, and where they   might fit. So this idea whether nature-based  approaches would be a, sort of, addon, or an   adjunct, to interventions that are already being  delivered, or as an intervention in its own right. And so, the second thing here was a theme around  potential enablers for implementation, and so,   this was really all centred around buy-in and  government support. So, staff described how   involvement from all stakeholders, so children  and young people, parents, staff at all levels,   would support with buy-in into this new, kind  of, way of working. Staff also talked about how   their own experiences of being in nature played a  role in their openness to exploring nature-based   approaches in their work. And how this, kind  of, first-hand experience could be important,   in terms of helping others to understand the  potential benefits of working in this way. And, last but not least, demonstrations  of support from leadership. So,   things like providing time,  putting structures in place,   and space for staff to engage in these new  ways of working. And the third theme that   came out of the qualitative work was around the  potential benefits of nature-based approaches   for staff and service users in CAMHS, which  Beth will now describe in the next few slides. Beth Chapman Thank you. So, yeah, the  benefits were those three subthemes,   as well. One of those was around increased  choice and individuation of the therapy   session. So staff really felt that both the staff  and the young people might have a say in how and   where a session was held. So it’s not just in  the clinic room every week, it’s like, “Well,   we could go somewhere else. We could go and do  something in the garden,” if they have a garden,   or, “We could go out somewhere else,” and it’s –  it was about being given permission to do that. And the staff really felt that that might  impact on the engagement of the young person,   both getting into CAMHS in the first place, where  they might be quite apprehensive, and then how   they engaged with the intervention once it had  started. So, a quote here, “Mostly, it’s more to   do with having it as an option as a space to work  in. So, say if we’re working with a young person,   making sure that we can meet them halfway, and if  that’s something that they would usually be doing,   is going out for a walk with mum or dad,  going to the forest or something like that,   then we could consider that as a place to  meet them. And we don’t have to be in the   home or a clinic, because sometimes those  places aren’t very comfortable, or aren’t   they easy for our patients either.” And that’s  really important, is making that young person   as comfortable and as relaxed as possible,  to be able to engage and to able to talk. “When you use an nature-based approach,  or a more informal approach, it doesn’t   become that scary for young people.” So it  offers them a different kind of support. So   these were things that the staff were thinking  intuitively it might – how it might benefit the   young people. And different staff thought  that it might benefit different subgroups,   which was interesting. So, some staff thought  it might support those more with low mood,   some thought it might help them with social  anxiety, those with sensory processing,   or neurodiversity, or ADHD, so, really,  it covered right across the spectrum The second subtheme was about the – enhancing  the quality of the therapeutic interventions   themselves. So, if a young person is in a  relaxed, safe space, or feeling in that space,   then they are more likely to be able to be aga  – engaged and attentive to their therapy. So it   may also improve their mood, so that they feel  more motivated to engage with that therapy. But,   of course, staff also identified that it can  benefit them in a similar way. So one person said,   “Young people that I’ve worked with in the  clinic space, when we’ve gone outside, they’re   more verbal.” “Just general walking out, often  walking is a nice parallel activity, especially   with young people that struggle with sitting  down and starting at the questions, sometimes   having walking can take the pressure off the  conversation, and make them feel a bit more open.” And then this last one was about very  specific therapeutic interventions, so,   “I think it’s helped people manage things like  dissociation and grounding, literally.” “Okay,   what can you feel on your skin?” “I can  feel the wind.” Or, if it’s been snowing,   “How does that feel in your hand? What can you  see?” So, sometimes it can be very challenging   to do a useful mindfulness activity in a clinical  room, when you’re drawing attention to things that   you might not want to be drawing attention  to, like the smell, or the bright walls,   or the noise next door, but, actually, going  outside it can be – could be more useful. And then the third theme was this new way  of working being pre – using this way,   and the discussion around autonomy, about being  creative. As Marie-Claude mentioned earlier,   there is this crossover between using nature-based  approaches and having creative activities,   enabling flexibility for the staff and  the young people. Staff also thought that   it might improve their skills, diversify  their skills, and they might, crucially,   enjoy their job more, which would lead to  their job sati – increased job satisfaction. Staff also identified that working in this  way could bring longer-term benefits for the   young people, once they’d left their journey  with CAMHS, so resourcing them to be able to   use these techniques throughout  their life. So, I like this one,   “I think as part of engagement, as part of  ending, as part of building up resources,   reclaiming life, there’s a huge role for more  nature-based connection.” And it’s helping young   people transition, so that they’re not reliant on  the Therapist, that’s what was being identified. So, if we try and link this now to some more  of those theoretical models of how nature could   be beneficial to us, I mean, it’s – we all know  that this is a complex intervention, the outcomes   are complex, and there’s so many variables. The  individual that’s going into these interventions,   the provider of them, what we’re actually doing,  and it – but i – that doesn’t really matter,   but it makes it really hard to work out what’s  going on. And all these things interact with   each other, so it’s – although we’re identifying  different ways, of course, they all crossover. The biophilia hypothesis, that I’m sure  everybody’s aware, with this idea that   because we’ve evolved in nature, we have  this innate attraction to all things living.   And we’ve worked out spaces where we are safe  and we can thrive, and what’s a threat within   that environment. And when we’re not in a  natural environment, a living environment,   that can actually be intrinsically stressful to  us, that we have an innate curiosity about – an   awe and wonder for nature, and that we are  attracted to it that way. And this – the   theory around stress is that not only is it  stressful if we are removed from nature, but,   actually, nature can help build a resilience to  stress. So, acute stress response and a chronic   stress response, and we know that chronic  stress is now – is linked with inflammation,   it’s linked with suppressed immune system, and the  gut microbiome that also was spoken about earlier,   so it’s lots of systems, all  interplaying with each other. Yet, if we use the ground-up approach  that Bessel van der Kolk talks about,   Steve Porges in the Polyvagal Theory, if we are  able to ground ourselves in nature and create this   sense of safety, then maybe we can use that later  on. We can learn that that’s a helpful technique,   and we can also engage more in what’s being  offered. And, of course, the attention   restoration that was spoken about earlier, it  – we’re not sure which bit of the attention   it is that it’s key for, but it does seem to be  around executive function. So that’s the working   memory and the self-control, and that can all  be so useful for pretty much everybody, really. Connection and wellbeing, I think Catriona’s going  to talk a little bit about later, but, of course,   that’s really important, and then the physical  activity, physical activity linking to mental   and physical health, so, so important. And then  these two other flowers that I’ve just put on,   I mean, there’s three flowers that I’ve  created with petals on, but, actually,   this would be a meadow of wildflowers.  They’re all these different things and   they’re all very different for different  people, but they essentially create their   own ecosystem of how they’re going to benefit an  individual, or a group, or a whole population. But the purply-pink flower, enhancing the  therapy, that could be around, like I said,   the emotional regulation being better when we’re  outside. It could be about using – you know,   nature lend itself – lends itself to metaphors  and that happens very naturally, you know. You   see a tree that maybe has had some adversity  on it and, actually, it grows up differently,   it grows up potentially stronger, it grows  up potentially taller, and that’s very nice   to be able to talk about different subjects,  that may be quite difficult to talk about,   when talking about them about themselves, but  when it’s out here, it can be easier. And,   again, our young people may be more able  to, once they’re outside and connected,   think beyond themselves, and that’s what  staff really thought they would be able to do,   think bigger, think about their environment,  think about world and connections. So, I mean,   I could talk more about – okay, two  minutes, I won’t talk more about that. And then the next workshop that we  did was with Siobhan and the team,   and this was a – quite a structured  workshop with our young people. Again,   we did two parallel sessions with the young people  and the carers, and it was really interesting,   and we asked them – so this time we’re asking  them not “Do you think it’s a good idea?” But,   “How do you think nature-based approaches  could benefit you within CAMHS?” And they came out with very similar themes to  what the staff thought, around anxiety reduction.   The autonomy and choice one was really, really  important. I hadn’t – so, maybe naively, I hadn’t   realised quite how important that would be, around  grounding, they identified that, individualisation   of care, engagement, connection to others and  to nature, and the sense of perspective of where   they are in their lives. And these wonderful trees  were what Hélène from the team and Siobhan pulled   together on this poster, from the leaves that all  the young people had written, these points down,   and it’s really beautiful. Interestingly,  risk didn’t come up with the young people. So, just to end on, just to think – I used this  analogy once before, about this journey has been a   bit of a snakes and ladders board. You feel like  you’re just getting somewhere, climbing up the   biggest ladder of the board and going to be right  at the top, and then there’s – you hit a snake and   you go sliding down to the bottom, so it’s really  been like that. But, here, enablers have been,   for me, to do this, have been getting the  Mental Health Research Initiative Fellowship,   it gave me that time, it gave me the connection,  it gave me the support, and the opportunities. Having that initial support, so, like I  mentioned, my colleague Gemma Morshead,   and from some other key leaders around us at the  time. And then being given the funding for the   training, so for the 16 staff that I mentioned,  and to do those two introductory awaydays,   we had to have that buy-in. And then, as  we got further in and I had that film,   we had buy-in from the Chief Executive,  the Medical Director, and the board. Challenges have been keeping the momentum going.  There’s always going to be competing clinical   priorities. And also having this, sort of, dual  strands of having the research and having this   absolute wealth of qualitative data and, also, the  information around staff wellbeing and burnout,   and trying to feed that into the  service, as change is happening,   and making that meaningful. It was challenging to  get operational support, although we’re there now,   and, also, the language that we were using,  and helping people to understand what we mean   by nature-based approaches, which can – is  also – can be ongoing difficulties with that. And so, next steps for us hopefully,  in two weeks’ time, we’ve got another   PPIE workshop and this time we’re going  to be asking the young people, “Okay,   these are the benefits that you’ve identified,  how do you think we should measure them? What   measurements do you think we should be using  to capture this?” We now have nature-based   approaches embedded with all – within all our  new care options. So all clinical pathways   for our young people now have nature-based  approaches, in some way, embedded within them. It’s not a perfect system. We’ve just, sort of,  landed it. It’s going to evolve and it’s going to   take more training for staff to really work this  out, but that structure is now there. Of course,   doing an implementation study  around this would be brilliant,   and working out exactly how to evaluate the  impact on our children and young people,   as well as our staff, would also be  brilliant too. And that’s the end, thank you.